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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_819_Библиотеки_им_академика_М_И_Перельмана
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11.9 3D Body Visible System- Clinical Applications inLiver Surgery
107
a
c
b
d
Fig. 11.4 (a) Each segment can be colored with a different color. (b) The liver can be rotated in any direction. (c) Vasculo-biliary structures can
be put back. (d) The liver can be made transparent
Fig. 11.5 Each liver can be made transparent and/or removed
108
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11 The Three-Dimensional Body Visible System inLiver Surgery
a
Fig. 11.6 Position of tumor in relationship to the liver segments. (a) Couinaud’s liver segments. (b) Tumor in liver segments 5 and 8
a
b
b
c
Fig. 11.7 Non-anatomical resection
a
11.9 3D Body Visible System- Clinical Applications inLiver Surgery
109
b
c
d
Fig. 11.8 Demerits of non-anatomical liver resection
the middle hepatic vein (MHV). Care should be taken to
preserve the segment 4 vein to prevent congestion of segment 4 after liver resection.
3. Amount of Liver Resection Margin
In the study by Shi M, etal., in anatomical resection, a 2cm
resection margin resulted in less long-term recurrence
than a 1cm margin. Thus if liver function allows, a 2cm
resection margin should be aimed. Subsegmentectomy
of the central liver segment (liver segments 4, 5, 8) can
increase the liver resection margin.
11.9.4 Simulation Hepatectomy
Using the 3D Body Visible System of the liver, simulation hepatectomy can be carried out. Such a procedure is facilitated by:
110
a
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11 The Three-Dimensional Body Visible System inLiver Surgery
1. The System showing the relationship of the tumor with
the vasculo-biliary structures (Fig.11.12).
2. In the transection plane of the simulated hepatectomy, all
major vasculo-biliary structures that need to be transected
can be shown (Fig.11.13).
3. To estimate the volumes of the part of the liver which is
going to be removed and the future remnant liver.
There are many ways to calculate:
1. Percentage
2. Absolute volume
3. Ratio of volume to Body Surface Area (BSA)
4. Ratio of volume to body weight
11.9.5 To Find Out Vasculo-Biliary Anomalies
1. Hepatic Artery
Usually the anomalies are extrahepatic, which can
make liver resectional surgery easier (Fig.11.14).
2. Portal Vein (Figs.11.15 and 11.16)
Portal Vein anomalies are usually intrahepatic
(Fig.11.17).
3. Hepatic Vein Anomalies
Segment 4 vein (Sg 4V) present in 57.4%, umbilical
vein (UV) present in 60%.
In 10% of patients, inferior right hepatic veins are so
large that it can be seen on CT scan (Fig.11.18).
In liver transplantation, if the right liver is used as a
donor graft, transection of a large right inferior hepatic
vein can result in congestion of liver segment 6. The solution is to do a vascular reconstruction to improve the
venous drainage of liver segment 6.
4. Bile Ducts
Usually, bile ducts are not visible on CT scan. They
can be visible when they are dilated, especially if contrast
has been injected into the biliary system by a percutaneous transhepatic biliary drainage tube (Fig.11.19).
Fig. 11.9 Right hepatectomy is technically easier
b
Fig. 11.10 HCC compressing on right hepatic vein (RMV)
a
11.9 3D Body Visible System- Clinical Applications inLiver Surgery
Fig. 11.11 Hepatocellular carcinoma very near to middle hepatic vein
111
b
a
c
b
d
Fig. 11.12 Relationship of tumor to vasculo-biliary structures. (a) Hepatic artery. (b) Portal vein. (c) Hepatic vein. (d) Combination of vasculo-
biliary structures
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11 The Three-Dimensional Body Visible System inLiver Surgery
a
c
b
d
Fig. 11.13 Simulation hepatectomy. (a) Liver transection plane showing transected vessels and bile ducts. (b) Liver transection plane viewed
from the front. (c) Liver transection plane viewed from the right. (d) Liver transection plane slightly oblique
11.9 3D Body Visible System- Clinical Applications inLiver Surgery
113
a
c
b
d
Fig. 11.14 (a) Normal anatomy. (b) Right hepatic artery from aorta, left hepatic artery from left gastric artery. (c) Left hepatic artery from left
gastric artery. (d) Left hepatic artery from left gastric artery, right hepatic artery from SMA
114
VI
III
a
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11 The Three-Dimensional Body Visible System inLiver Surgery
a
b
Fig. 11.15 (a) Normal anatomy. (b) Blocked main portal vein with development of collaterals
VIII
PV
hp
hp
IV
up
I
IV
up
I
II
III
II
III
IV
V
VIII
hp
VII
c
VIII
VI
VII
PV
V
II
hp
PV
up
I
IV
up
II
III
II
I
b
VI
VII
d
VI
VII
V
V
VIII
e
LPV
Fig. 11.16 (a) Trifurcation. (b) Right anterior sectoral portal vein drains into left portal vein. (c) Left portal vein supplying the whole liver
PV
11.9 3D Body Visible System- Clinical Applications inLiver Surgery
115
a
Middle hepatic vein
Accessory right
hepatic vein
Right
hepatic
vein
Segment 8 branch
c
7
8
5
Segment 5 branch
Segment 4 vein
4
Segment 4 branch
Umbilical vein
Left hepatic vein
2
Segment 2
3
Segment 3 branch
branch
d
b
Fig. 11.17 Portal vein anomalies (Segment 4 vein and umbilical vein)
116
a
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11 The Three-Dimensional Body Visible System inLiver Surgery
Right
inferior
hepatic
vein
Small right hepatic vein
b
Main hepatic vein
Left hepatic
vein
c
Fig. 11.18 (a) Large right inferior hepatic vein. (b) Large right inferior hepatic vein
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